左冠状动脉主干血管成形术

目的介绍单一性左冠状动脉主干狭窄的外科手术方法.方法回顾性总结采用血管补片成形术治疗单一性左冠状动脉主干病变的手术结果.结果本组8例患者均存活,无围手术期心肌梗死等严重并发症发生,平均随访时间5年4个月;其中1例患者于术后6个月因心绞痛复发而行冠状动脉旁路移植术,术后无并发症发生;其余患者心绞痛症状均完全消失,并参与正常活动.结论冠状动脉主干血管成形术可作为单一性左冠状动脉主干狭窄的外科手术方式之一,但不宜用于病变血管处有管壁严重钙化的患者.     

冠状动脉左主干病变双源CTA影像学特征及临床应用

目的探讨冠状动脉左主干病变(LMCD)的双源CTA影像特征及临床应用。方法回顾性分析经双源CTA诊断的LMCD患者33例,分析其临床资料,按照左主干50%,左前降支、回旋支或右冠状动脉≥70%定义目标血管,经CT图像后处理,于心脏短轴层面观察节段心肌密度,分析其影像特点,同期行CAG,术后随访3个月。结果 33例患者中,双源CTA确定目标血管75支,以CAG为金标准,CTA诊断主要血管病变72支,准确率96.00%(72/75),9支(9/33,27.27%)冠状动脉左主干为单纯LMCD,24支(24/33,72.73%)LMCD合并其他主要血管病变,其中20支冠状动脉左主干合并末端岔口病变。29例(29/33,87.88%)例患者46节段CTA显示心肌密度减低,23例34节段位于心内膜下,6例12节段为透壁性。对42支(42/75,56.00%)血管行经皮冠状动脉介入治疗(PCI),其中22支病变局限、行单纯PCI,20支为左主干末端岔口病变、行PCI同时覆盖左前降支或回旋支开口。13支(13/75,17.33%)采用冠状动脉旁路移植术,20支(20/75,26.67%)采用药物保守治疗,随访3个月,未发现主要不良心血管事件。结论冠状动脉双源CTA可发现LMCD部位及范围,发现其他血管病变及异常血流灌注的节段心肌,为临床病情评估及治疗提供客观依据。     

冠状动脉旁路移植术治疗左主干分叉病变

目的探讨冠状动脉左主干分叉病变的外科治疗方法,总结其临床经验。方法1999年3月至2008年4月我院共收治29例冠状动脉左主干分叉病变患者,在体外循环心脏不停跳下行冠状动脉旁路移植术（CABG）,观察体外循环时间、术后呼吸机辅助时间、ICU时间、住院时间、围术期以及随访情况。结果体外循环时间为48．2±15．5min,术后呼吸机辅助时间14．2±4．6h,住ICU时间3．3±0．8d,住院时间18．0±2．7d,无围术期心肌梗死发生。本组患者随访7～98个月（29．0±19．2个月）,25例心绞痛症状完全消失,2例心绞痛症状缓解,3例于术后3年、4年和8年分别死于脑血管病变、心脏骤停及肺癌。超声心动图检查提示：左心室收缩功能获得不同程度的改善。结论冠状动脉左主干分叉病变应用体外循环心脏不停跳CABG可以取得良好的治疗效果。     

左冠状动脉主干严重狭窄行急诊冠状动脉旁路移植术九例

左冠状动脉主干严重狭窄者心肌缺血严重 ,一旦出现严重心绞痛或 /和急性心肌梗死可突然死亡 [1 ]。 1999年 1月～2 0 0 0年 11月 ,我们为 9例患者行急诊冠状动脉旁路移植术(CABG) ,取得了满意的临床效果。1　临床资料与方法1.1　一般资料　本组共 9例 ,男 7例 ,女 2例 ;年龄 5 6～ 70岁 ,平均年龄 6 3.2岁 ;体重 6 0～ 75 kg,平均体重 71kg。所有患者均诊断为冠状动脉粥样硬化性心脏病 (冠心病 ) ,按 WHO诊断标准 ,诊断为急性心肌梗死 (AMI) 4例 ,均为广泛前壁AMI。有高血压病史 5例 ,糖尿病史 1例 ,脑出血史 1例 ,上消化道出血史 1例…     

左冠状动脉主干重建术治疗孤立性左冠状动脉主干狭窄

左冠状动脉主干重建术治疗孤立性左冠状动脉主干狭窄高长青朱朗标李伯君肖苍松作者单位：１００８５３解放军总医院心血管外科图１术前冠状动脉造影（左前斜位）示ＬＭＣＡ开口重度狭窄图２术前主动脉造影（左前斜位）示ＰＤＡ粗大图４术后冠状动脉造影（左前斜位ＬＭＣＡ...     

无保护左冠状动脉主干狭窄介入治疗患者的护理

对46例无保护左冠状动脉主干狭窄患者行介入治疗.结果 46例均完成手术,术后发生心绞痛8例,血压下降15例,右颌下血肿1例,心脏压塞1例,穿刺部位渗血2例,尿潴留3例,经对症治疗护理,患者均痊愈出院.提出完善术前准备,做好术后病情观察、及时识别和处理介入术后并发症对患者的预后有积极影响.     

无保护左冠状动脉主干狭窄介入治疗患者的护理

对46例无保护左冠状动脉主干狭窄患者行介入治疗。结果46例均完成手术,术后发生心绞痛8例．血压下降15例,右颌下血肿1例,心脏压塞1例,穿刺部位渗血2例,尿潴留3例,经对症治疗护理,患者均痊愈出院。提出完善术前准备,做好术后病情观察、及时识别和处理介入术后并发症对患者的预后有积极影响。     

非体外循环下冠状动脉旁路移植术治疗左冠状动脉主干合并3支血管病变

目的总结非体外循环冠状动脉旁路移植术(OPCAB)对左冠状动脉主干合并3支血管病变患者的治疗经验及体会。方法对33例左冠状动脉主干合并3支血管病变患者施行了OPCAB,用左乳内动脉作为移植血管与左前降支进行吻合,大隐静脉作为移植血管分别与回旋支、右冠状动脉/后降支、对角支和钝缘支进行吻合。结果每例患者行旁路血管移植2～5支,平均3.4支。无手术死亡,无围手术期心肌梗死、呼吸衰竭、肝肾功能衰竭等严重并发症,术后心绞痛均消失。结论OPCAB治疗左冠状动脉主干合并3支血管病变的高危冠心病患者是可行、有效的,手术损伤小;而积极的术前准备、主动脉内球囊反搏的应用、正确的手术方法和配合、建立一支熟练快速的应急队伍是确保手术成功的关键。     

225例左主干狭窄冠状动脉旁路移植术

目的 总结冠状动脉左主干狭窄(LMS)的外科治疗效果和临床经验。方法1999年1月至2003年6月，225例LMS病人接受了冠状动脉旁路移植术(CABG)。平均年龄63．4岁。左室射血分数(LVEF)≤0．3011例。6例急诊手术，其中3例术前放置主动脉球囊反搏(IABP)。76例在常规体外循环下手术；149例应用非体外循环不停跳技术，术中改为体外循环5例。其中13例全动脉化、3例全静脉化旁路移植术。结果平均术前住院2．3d。平均每例远端吻合口2．95个。死亡13例(5．78％)。结论尽管LMS是预示CABG术后死亡率的独立危险因素，但CABG现在仍是其治疗的第一选择，且是安全、有效的方法。     

Congenital atresia of the left main coronary artery: management of a 5-year-old child in extremis

Atresia of the left main coronary artery is a rare coronary anomaly. We describe the case of a 5-year-old child presenting in emergency in extremis. Clinical findings of haemodynamic collapse, malignant ventricular tachyarrhythmias and severe mitral regurgitation were indicative of a possible ischaemic aetiology. Surgical revascularization of the atretic left main coronary artery segment using an interposition autologous saphenous vein graft was successfully performed.     

Outcome and selection of revascularization strategy in left main coronary artery stenosis

Objectives. To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy. Design. Consecutive patients with ULMCA stenosis at our institution in 2009–2013 (n?=?308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression. Results. Patients that underwent PCI (n?=?94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08–4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50–2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG. Conclusions. In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.     

Acute myocardial infarction due to left main coronary artery occlusion

OBJECTIVE: Acute myocardial infarction due to left main coronary artery occlusion remains catastrophic and mostly fatal due to severe cardiogenic shock and arrhythmia. METHODS: We studied 13 patients undergoing coronary artery bypass grafting for acute myocardial infarction due to left main coronary artery occlusion to clarify the optimal management of these difficult patients. RESULTS: In-hospital mortality was 46.2% (6/13). Revascularization was achieved by catheter intervention followed by bypass surgery in 7, and bypass surgery alone in 6. Two bypass surgery patients without catheter intervention had collateral flow to the left coronary artery, with the right coronary artery dominant. The time from onset to recanalization in the survival group was significantly shorter than in the early death group. CONCLUSIONS: Emergency intervention to preserve left ventricular function or right coronary artery dominant and collateral blood flow to left coronary arteries is important for improving the prognosis of patients with acute myocardial infarction due to left main coronary artery occlusion. If residual left main coronary artery stenosis is significant or other proximal coronary stenosis exists after catheter intervention, early coronary bypass surgery may improve long-term survival.     

Grade of left main coronary artery stenosis does not influence long-term mortality after coronary artery bypass surgery

Objective. To assess if grade of left main coronary artery (LMCA) stenosis influences early or long-term mortality after coronary artery bypass grafting (CABG). Design. Among all 1 384 patients with LMCA stenosis at Karolinska Hospital, Stockholm, Sweden during 1990–1999, 131 deaths occurred within 5 years of surgery (cases). Matched controls (n=146) were randomly selected from all surviving LMCA patients taking gender, age and year of surgery into account. Angiographies were classified for grade of LMCA stenosis before the operation. Results. High-grade LMCA stenosis was equally common among cases and controls (50 vs. 45%). The odds ratio (OR) of mortality 5 years after the operation in patients with high-grade versus low-grade LMCA stenosis based on the matched pairs was 1.2 (95% confidence interval (CI) 0.7–2.0) and after multivariable adjustment using information on all subjects the OR was 1.0 (95% CI 0.6–1.7). For early and one year mortality similar odds ratios were observed but with wide confidence intervals. Conclusions. Grade of LMCA stenosis does not appear to influence early or long-term mortality after CABG performed during 1990–1999.     

Surgical treatment of a left anterior descending artery to the main pulmonary artery fistula

We report a case of surgical treatment of a 58-year-old symptomatic patient with large coronary artery fistula, which drained from the left anterior descending artery into the main pulmonary artery (PA), and concomitant large patent foramen ovale. The surgery was performed through a median sternotomy with aortobicaval total cardiopulmonary bypass. The PA was incised. The fistula was identified 5 mm above the anterior leaflet of the pulmonary valve and was closed off using a prolene suture. Afterward, the atrium septum defect was closed with a Dacron patch via the standard right atrium access. There were no postoperative complications.     

High mortality after coronary bypass surgery in patients with high-grade left main coronary artery stenosis

Objective. To determine mortality after coronary artery bypass grafting (CABG) in relation to degree of left main coronary artery (LMCA) obstruction. Design. All patients without LMCA stenosis (n=3370), with low-grade stenosis (n?=?261), high-grade stenosis (n?=?224) or total occlusion of the LMCA (n?=?15) were followed for ten years after CABG performed during 1970–1989. Results. Early mortality was 1.9% and 2.3%, respectively, if there was no or a low-grade LMCA stenosis vs. 6.3% if the stenosis was high-grade. Ten-year survival was 76% if no LMCA obstruction, 74% if low-grade stenosis and 64% if the stenosis was high-grade. Risk of early death (odds ratio 2.6, 95% CI 1.4–4.8) and mortality at ten years (relative risk 1.5, 95% CI 1.1–2.0) was higher in patients with high-grade stenosis than in those without LMCA stenosis. There was no increased long-term mortality in patients with low-grade stenosis or among the few patients with occlusion of the LMCA. Conclusions. High-grade LMCA stenosis was associated with a three-fold increased risk of early and fifty percent higher risk of late death than in patients without LMCA stenosis.